Indications are that the public health burden of sleepiness-related injuries is likely increasing, given recent trends in drowsy driving. The National Sleep Foundation found that self-reported drowsy driving has increased significantly over the past years, from 51 percent of respondents in 2001 to 60 percent in 2005 (NSF, 2005). Similarly striking was that more than 10 percent of the entire sample reported nodding off or falling asleep while driving at least 1 to 2 days per month.

The impact of driver sleepiness is similar in magnitude to that of alcohol consumption. A study of all crashes between 1990 to 1992 reported to North Carolina’s uniform reporting system found that fall-asleep crashes (ones in which a law officer determines the driver to be asleep or fatigued) and alcohol-related crashes were similar in terms of serious injuries (13.5 and 17.8 percent of crashes from all causes, respectively) and fatalities (1.4 and 2.1 percent of all fatalities, respectively) (Pack et al., 1995). In actual driving performance on a closed course, sleep-deprived adults performed as poorly as did alcohol-challenged adults (Powell et al., 2001). After a night of total sleep deprivation, impairments in lane-keeping ability were similar to those found with blood alcohol content of 0.07 percent (Fairclough and Graham, 1999).

Fall-asleep crashes have distinct patterns by type, age, and time of day. According to the North Carolina study, fall-asleep crashes are largely off-the-road and at higher speeds (in excess of 50 mph) (Pack et al., 1995). Adolescents and young adults between the ages of 16 and 29 are the most likely to be involved in crashes caused by the driver falling asleep (Horne and Reyner, 1995; Pack et al., 1995). They account for about 50 percent of all crashes (Horne and Reyner, 1995; Pack et al., 1995). Fall-asleep crashes occur at two periods of day that coincide with circadian variation in sleepiness, in the early morning (2:00 a.m. to 8:00 a.m.) (Pack et al., 1995; Connor et al., 2002) and during the midafternoon (Horne and Reyner, 1995; Pack et al., 1995; Carskadon, 2004). The most common reasons behind fall-asleep crashes are working multiple jobs, night shift work, and sleep duration of less than 5 hours (Connor et al., 2002; Stutts et al., 2003).

Sleep apnea accounts for a small, but measurable percentage of motor vehicle crashes, primarily in drivers above the age of 25 (Sassani et al., 2004). Individuals with sleep apnea are at twice the risk of having a traffic accident as unaffected individuals (Teran-Santos et al., 1999)—the higher the apnea-hypopnea index, the higher the risk (Young et al., 1997a). Sleepy drivers tend to display reduced vigilance, slow reaction times, and loss of steering control. Steering impairment in OSA, sleep deprivation, and alcohol intoxication was compared in a controlled clinical trial. Untreated OSA and sleep deprivation were similar in producing progressive steering deterioration throughout the drive, whereas alcohol-impaired individuals steered equally throughout the drive (Hack et al., 2001). Occupational groups at



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